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Review of the Massachusetts Group Insurance Commission Physician Profiling and Network Tiering Plan

Engaged Focused Medical Analytics (FMA), Rochester, NY and J. William Thomas of Univ. of Southern Maineto examine their methodologies for cost and quality ratings, their process for implementation and make recommendations for improvement

Physician Focus Groups

Engaged Howard Beckman, MD, to gain a better understanding of how Massachusetts’ physicians view quality and efficiency measurements and reporting.

Physicians did not believe their current experience of reporting programs, especially those that publicly report or tier, are fair or meaningful because the data is inaccurate and the measures insufficient to determine a clinician’s true quality or effectiveness.

“You lose your confidence in these measures because you don’t believe they’re going to generate anything that is legitimate or accurate . . .there are so many loopholes, so many things that slip through the cracks that shouldn’t be there, that they don’t even have credibility.”“It will bother me if I don’t know what I’ll be evaluated on and if I feel that they have the wrong data”

Physicians perceived that more judgmental programs, like tiering and public reporting at the individual level, use the fear of humiliation to influence practitioner’s behavior and affect the physician’s professional standing.

“We don’t know what we are being graded on. How can you be judged on something when you don’t know what you’re being judged on?”“One of my partners has called [a health plan] and said, ‘what are you talking about here, how are we being tiered, what do you want us to do if it has to do with patient care, quality of care? Don’t you want that improved by everybody?’ They talk about transparent medical record, how about a transparent HMO.”

Physicians in all disciplines agreed that quality and efficiency performance measurement is appropriate if the data is accurate and actionable, the measures clinically meaningful, and the incentive payment methodology clear and fair

“I don’t think any of us mind the game when the game is supposedly to improve the quality of care. If there’s a game to improve care, sign me up. I’ll play that game. But when the game is unfair and the rules are all askew, that’s where the problem is.”

“I think it does need to be done in some way, but it needs to be done with great care.”

Forge a partnership between health plans, employers and practitioners. Physicians felt excluded from a seat at the table. Those participating now understand that they have to become MORE involved in creating an actionable, meaningful set of measures that can be reported accurately and fairly.

“I think that physicians were slow to do it [performance measurement] and insurance companies, with all the money and administrative power, do these things . . . There are scorecards employers use to rate plans.’“What the HMO can do is see if the patient regularly refills prescriptions, and if they find there is non-compliance they can notify the physician or patient.”“We should, as physicians, get together and tell them how to do it.’